Provider Demographics
NPI:1992221469
Name:BERNARD, LANCE WAYNE (MS, LAT, ATC, OTC)
Entity Type:Individual
Prefix:MR
First Name:LANCE
Middle Name:WAYNE
Last Name:BERNARD
Suffix:
Gender:M
Credentials:MS, LAT, ATC, OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7925 BELLA FLORA DR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76126-6070
Mailing Address - Country:US
Mailing Address - Phone:817-487-1466
Mailing Address - Fax:
Practice Address - Street 1:2901 ACME BRICK PLZ
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4124
Practice Address - Country:US
Practice Address - Phone:817-529-1900
Practice Address - Fax:817-529-1910
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-16
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
TX0104021062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer